Next to Ebola, my favorite virus would probably be smallpox (Variola virus). I mean, now that it’s eradicated in nature, what’s not to love about the mysteries it’s left us–where it came from, why it was so deadly (or, not so deadly, as in the emergence of the “mild” form, variola minor), and will a new poxvirus emerge to take its place? The topic is particularly germane since the debate still rages on about the fate of theworld’s smallpox stocks. Smallpox has killed untold millions and influenced the destiny of societies; and as Michael Willrich details in his new book, Pox: An American History, the legacy smallpox has left us is still alive and well today.
Willrich focuses his energy on an approximately 3-year period in American history, from roughly 1900 to 1903. This was a period which saw the beginning of the end of smallpox in America, and the last of the major outbreaks of smallpox in many of our large cities. It was also a time of change in the epidemiology of the virus itself, with the spread of the milder form of the virus (“Variola minor”) overtaking the deadlier form (“Variola major”) in many parts of the U.S. This epidemiological shift led to a number of issues in smallpox control. First was the basics of diagnosis. Many physicians, particularly in rural areas where smallpox was not a constant visitor, were unsure if the new and milder form of smallpox was really smallpox at all, rather than another rash disease. Even if an epidemic was underway, a fatality rate of only a few percent (as compared to 30% or more for previous outbreaks) led them to believe that, perhaps, this new form left little to be worried about, and led to complacency over quarantine and vaccination. Willrich spends much of the early chapters of the book focusing on this problem, and the way different communities and cities dealt with these new visitations of smallpox. It’s a compelling read, with conflicts between local, state, and federal authorities, as well as divides between groups of different races and social classes (and inaction on the part of authorities when it’s thought that the epidemic is limited only to the “lower” classes).

Willrich also describes the steps these different locales went to when it was clear an outbreak was upon them, and needed to be controlled. The records are replete with instances of forced vaccination (sometimes, literally, at gunpoint) both here within the continental states and also in Puerto Rico and the Philippines, where American soldiers were stationed following the Spanish-American war. “Pox” also details the fight against such compulsory vaccination, and how those campaigns still echo in our society today. Some have obvious lineages, such as how the arguments of the anti-vaccinationists of the early 1900s really haven’t changed in over 100 years. Indeed, they had their own celebrities of the day; they claimed the right to become infected with smallpox and let their own bodies handle the infection; they believed that being vaccinated would “weaken the constitution” in the same way modern-day anti-vax groups claim that the vaccines “overwhelm” the immune system; they even had a memorial to “victims of vaccination,” much like the National Vaccine Information Center’s “Memorial for Vaccine Victims”; and they knew how to use and manipulate the media. However, there is one big difference: compared to our vaccines today, the smallpox vaccine has long been known to be one of the least safe vaccines we have, and there were outbreaks of infections (especially tetanus) which had been associated with the vaccine in the early 1900s.

However, Willrich also spends quite a lot of time showing how it was just these outbreaks (recognized and detailed by scientists such as Dr. Theobald Smith of the Massachusetts Board of Health and others) that led to significant vaccine reform, and ultimately to federal licensing and oversight of vaccine manufacture (as well as to oversight by the precursor to the National Institutes of Health). Vaccines had to be routinely tested, and batches could be recalled if contamination was found. It was a large expansion in the federal government’s role in vaccination, one that had already been stretched since the beginning of the century.

And that stretching of federal authority–of the role government was allowed to play in mandating vaccination and punishing those who refused vaccination–is another central theme in “Pox.” Willrich describes many court cases throughout the country which tested this authority, and describes laws which were passed (or, not passed, depending on the case) in attempts to define and codify this role. He notes that, despite many courts ruling against the anti-vaccinationists, that they did not give up their fight, and cautions in the epilogue that current court decisions (and scientific evidence) denying any role of vaccines in the development of autism are not expected to silence today’s brand of vaccine dissenters. There is still much to be learned from history, and “Pox” is an engaging slice of it.

Sorry, the first part of my paragraph was accidentally deleted. This was what I meant to send.

You mention the stockpiles that the government (CDC) currently is holding, and that’s become somewhat of an issue. Do you have an opinion on this? I recently became familiar with this on another scientist’s website.

I’d be interested in getting your take on Dr. Salzberg’s opinion that the government should destroy the smallpox it still has in the labs.

Another non-scientist here, but I’m glad to know that I’m not the only one fascinated with Ebola – that is one CREEPY disease!

Mandatory vaccines are still a hot-button issue today and it is interesting to me to look back at the history of vaccines and the legislation relating to them. Thanks for taking the time to review this book.

You’re probably aware the April issue of Emerging Infectious Diseases has a pox theme. http://www.cdc.gov/EID for anyone who’s interested. The issues includes a couple commentaries on what to do with the stockpiled virus.

Matthew, a death rate of a “few percent” would have looked good at a time when measles had a mortality rate of 10% (it still does among children in sub-Saharan Africa), diphtheria routinely hit 20%, and typhoid can be up to 30%.

Yep. Mandatory vaccines are still a hot-button issue today and it is interesting to me to look back at the history of vaccines and the legislation relating to them. Thanks for taking the time to review this book.